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VANDIVORT DRUG (WISDOM DRUG LLC)
CHC26564-03 SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER
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Covered Entity Details
Entity Name
SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER
Subdivision Name
Four Rivers Community Health Center
Type
HRSA-Funded Health Center
340B ID
CHC26564-03
Entity Address
1081 E 18th St
Rolla, MO 65401
Grant Number
H80CS26564
Participating Start Date
1/1/2017
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
VANDIVORT DRUG (WISDOM DRUG LLC)
Pharmacy Address
117 W 4TH ST
SALEM, MO 65560-1255
Pharmacy Comments
Contract Details
Approval Date
10/13/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/25/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stuart Gipson, CEO
(573) 426-6714
Contract Pharmacy Representative
Wisdom Drug
Teel Wisdom, Owner/PIC
(573) 729-4114
Signed By Date
10/13/2020
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